Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19: A Living Systematic Review of Multiple Streams of Evidence.

BACKGROUND: Mechanical ventilation is used to treat respiratory failure in coronavirus disease 2019 (COVID-19). PURPOSE: To review multiple streams of evidence regarding the benefits and harms of ventilation techniques for coronavirus infections, including that causing COVID-19. DATA SOURCES: 21 standard, World Health Organization-specific and COVID-19-specific databases, without language restrictions, until 1 May 2020. STUDY SELECTION: Studies of any design and language comparing different oxygenation approaches in patients with coronavirus infections, including severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS), or with hypoxemic respiratory failure. Animal, mechanistic, laboratory, and preclinical evidence was gathered regarding aerosol dispersion of coronavirus. Studies evaluating risk for virus transmission to health care workers from aerosol-generating procedures (AGPs) were included. DATA EXTRACTION: Independent and duplicate screening, data abstraction, and risk-of-bias assessment (GRADE for certainty of evidence and AMSTAR 2 for included systematic reviews). DATA SYNTHESIS: 123 studies were eligible (45 on COVID-19, 70 on SARS, 8 on MERS), but only 5 studies (1 on COVID-19, 3 on SARS, 1 on MERS) adjusted for important confounders. A study in hospitalized patients with COVID-19 reported slightly higher mortality with noninvasive ventilation (NIV) than with invasive mechanical ventilation (IMV), but 2 opposing studies, 1 in patients with MERS and 1 in patients with SARS, suggest a reduction in mortality with NIV (very-low-certainty evidence). Two studies in patients with SARS report a reduction in mortality with NIV compared with no mechanical ventilation (low-certainty evidence). Two systematic reviews suggest a large reduction in mortality with NIV compared with conventional oxygen therapy. Other included studies suggest increased odds of transmission from AGPs. LIMITATION: Direct studies in COVID-19 are limited and poorly reported. CONCLUSION: Indirect and low-certainty evidence suggests that use of NIV, similar to IMV, probably reduces mortality but may increase the risk for transmission of COVID-19 to health care workers. PRIMARY FUNDING SOURCE: World Health Organization. (PROSPERO: CRD42020178187).

Lessons learned from the Baltic countries' response to the first wave of COVID-19.

The Baltic countries of Estonia, Latvia, and Lithuania shared a similar response to the first wave of the COVID-19 pandemic. Using the information available on the COVID-19 Health System Response Monitor platform, this article analyzed measures taken to prevent transmission, ensure capacity, provide essential services, finance the health system, and coordinate their governance approaches. All three countries used a highly centralized approach and implemented restrictive measures relatively early, with a state of emergency declared with fewer than 30 reported cases in each country. Due to initially low COVID-19 incidence, the countries built up their capacities for testing, contact tracing, and infrastructure, without a major stress test to the health system throughout the spring and summer of 2020, yet issues with accessing routine health care services had already started manifesting themselves. The countries in the Baltic region entered the pandemic with a precarious starting point, particularly due to smaller operational budgets and health workforce shortages, which may have contributed to their escalated response aiming to prevent transmission during the first wave. Subsequent waves, however, were much more damaging. This article focuses on early responses to the pandemic in the Baltic states highlighting measures taken to prevent virus transmission in the face of major uncertainties.